Claims processing is the the entire process of entering the procedures rendered until payment is collected or denial is determined. These procedures might be in the context of Medical Claims. When we talk of Claims Processing in Information technology, we talk about the applications developed for medical insurance industry.

Mainly, there are three types of claims as below1. Professional 2. Outpatient 3. Inpatient.

There are different types of plans like PPO, HMO, HSA, etc. These plans are assosiated with different contracts which have different types of benefits.

In Claim Processing there are mainly two types1. Manual Processing (Detail & Summary Type)2. System Adjudication

We have to enter the claims for the members under the above said plans. Then we have to log the claims into the system.If the claim goes for System Adjudication, after the batch run, we have to check whether the benefits are applied to the claim properly as mentioned in the contract assosiated with the plan.If the claim goes for Manual Processing, then we have to manually process the claims. There will be a setting in the system like if we press a function key say F2, then the benefits will be applied systematically. so, we have to manually process the claim by pressing F2 and verfiy whether the benefits are applied properly.

Interview & Career Tips

Get invaluable Interview and Career Tips delivered directly to your inbox. Get your news alert set up today, Once you confirm your Email subscription, you will be able to download Job Inteview Questions Ebook . Please contact me if you there is any issue with the download.